Safety of direct oral anticoagulants in the treatment of atrial fibrillation in geriatric patients: focus on clinically relevant non-major bleeding

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Abstract

Most studies examining the safety of direct oral anticoagulants (DOACs) in patients with atrial fibrillation have focused on major, life-threatening bleeding events. However, clinically relevant non-major bleeding (CRNMB) may lead to unnecessary prolonged withdrawal of DOACs, both by the patient and the physician, and, as a result, increase the risk of death and/or systemic thromboembolic complications. The article presents several classifications of types of bleeding: BARC, GARFIELD-AF, ISTH. An analysis of modern literature was carried out, as a result of which it was revealed that the incidence of CRNMB is higher than major bleeding and varies from 6.69% to 17.4%, the density of events for CRNMB was maximum 22.7 cases (95% confidence interval [16.3–30.8] per 100 patient-years) and the frequency of such bleeding had a direct relationship with the age of the patients studied: the older the population, the more frequent episodes of CRNMB occurred. The most common localization of CRNMB was in the gastrointestinal tract – up to 47%, genitourinary tract – up to 32.6% and skin – up to 17.6%. Based on the recommendations of leading cardiological societies to prevent bleeding, in addition to the HAS-BLED scale, additional prevention methods are presented, taking into account the age characteristics of the patient. As a current approach in the treatment of bleeding, it is recommended to determine the severity, identify and eliminate the source of bleeding. Discontinuation of DOACs during bleeding requires a personalized approach and, most importantly, prompt resumption of DOACs. At the same time, CRNMBoften require discontinuation of only one dose of the drug. Given that studies rarely present data on the incidence and pattern of CRNMB or data are presented in conjunction with other types of bleeding, it would be advisable that future studies regarding the safety of DOACs include more detailed information on the incidence of CRNMB, risk factors for its development, especially in geriatric patient populations.

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About the authors

D. A. Sychev

Russian Medical Academy of Continuing Professional Education

Email: doctor@cherniaeva.ru
ORCID iD: 0000-0002-4496-3680
SPIN-code: 4525-7556
Russian Federation, Moscow

Marina S. Cherniaeva

Central State Medical Academy of Department of President Affairs; Hospital for War Veterans No. 2

Author for correspondence.
Email: doctor@cherniaeva.ru
ORCID iD: 0000-0003-3091-7904
SPIN-code: 2244-0320

Cand. Sci. (Med.), Associate Professor of the Department of Internal Medicine and Preventive Medicine, Chief specialist in geriatrics of the Department of Healthcare, Head of the Department of Geriatrics

Russian Federation, Moscow; Moscow

M. A. Rozhkova

Hospital for War Veterans No. 2

Email: doctor@cherniaeva.ru
ORCID iD: 0009-0001-9329-7477
Russian Federation, Moscow

E. A. Moiseeva

Federal Medical Biophysical Center n.a. A.I. Burnazyan

Email: doctor@cherniaeva.ru
ORCID iD: 0009-0004-5050-4220
Russian Federation, Moscow

A. A. Pogodina

Pirogov Russian National Research Medical University

Email: doctor@cherniaeva.ru
ORCID iD: 0009-0009-2933-637X
Russian Federation, Moscow

Yu. S. Bayzel

Federal Medical Biophysical Center n.a. A.I. Burnazyan

Email: doctor@cherniaeva.ru
ORCID iD: 0009-0003-2035-5132
Russian Federation, Moscow

L. A. Egorova

Central State Medical Academy of Department of President Affairs

Email: doctor@cherniaeva.ru
ORCID iD: 0000-0001-9777-3832
SPIN-code: 8260-2686
Russian Federation, Moscow

O. M. Maslennikova

Central State Medical Academy of Department of President Affairs

Email: doctor@cherniaeva.ru
ORCID iD: 0000-0001-9599-7381
SPIN-code: 5516-9979
Russian Federation, Moscow

N. V. Lomakin

Russian Medical Academy of Continuing Professional Education; Central Clinical Hospital with at ambulant clinic

Email: doctor@cherniaeva.ru
ORCID iD: 0000-0001-8830-7231
SPIN-code: 8761-0678
Russian Federation, Moscow; Moscow

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